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Home My WebLink AboutNature Springs Water 10/4/2016Commonwealth of Massachusetts Town of Mansfield Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 5ermit to Operate a Food Service Establishmen Type: TEMPORARY FOOD PERMIT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. 171'l '• Whose place of business is: NATURE SPRINGS WATER CO. INC. - 9TH ANNUAL TRI -TOWN CHAMBER FOOD TASTING @ THE XFINITY CENTER 885 SOUTH MAIN STREET PERSON(S) IN CHARGE DAN ROMA, OWNER Permit Expires: October 04, 2016 Permit Expires: Permit Expires: Permit Expires: Food Fee: License Number: T-104 BOARD OF HEALTH michaeC.'lcCCean, Chairman WAIVED FOR BOARD OF HEALTH USE ONLY q,5 - Date Received Date Inspected Approved By Permit # Issued Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name;C, K, 2) Establishment Address:(- C,n L-A 'A 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 6) Applicant Name & Title: 6) Applicant Address: 7) Applicant Telephone No: 24 Hour Emergency No: k 8) Owner Name& Title (if different from applicant): 9) owner Address (if different from applicant): 10) Establishment Owned By: 0 An association 0 corporaon 0 , A An indKid'U-61 • A partnership • Other legal entity_ 11) If a corporation or partnership, give name, title, and home address of officers or partner. Name Title Home Address 4.cocz'-S'-�r 12) Person Directly Res ons ble For Daily Operations (Owner, Person In Charge, Supervisor, Manager etc.) Name & Title: Address: No: z Fax: -Telephone Telephone No: # � -Ernergengy District Or Regional $up rvisor(ifapplicabig) -13) & Tito: -Name -Address: -Telephone No: Fax: 590applicattoRb-2.(100 Food Establishment Information 14) Water Source: 15) Sewage disposal: rr Supply No: If applicable) i r )\' DEP Public Water ( 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person In Charge Certified In Food Protection Management: Re aired as of 10N/2001in accordance with 105 CMR 590.003 A ,, aae� dere. 19) Person Trained In Anti -Choking Procedures (If 25 seats or more): ® Yes tD No 20) Location: 22) Establishment Type(check all that apply) ❑ Caterer (check one) ❑ Retail ( Sq. Ft) ❑ Food Delivery o Permanent Structure ❑ Food Service — ( Seats) c3 Residential Kitchen for Retail Sate ❑ Mobile ❑ Food Service —Takeout ❑ Residential Kitchen for Bed and Breakfast ❑ Food Service — Institution Home ( Meals/Day) ❑ Residential Kitchen for Bed and Breakfast Establishments Other (Describe) ❑ Frozen Dessert Manufacturer 21) Length Of Permit: (check one) ❑ Annual ❑ Seasonal/Dates: ❑ Temporary/Dates/Time: Definitions: PHF— potentially hazardous food(thne/tempersture controls required) 23) Food Operations: Non -PRFs— non• potentially hazardous food (no tlmMemperature controls required) RTE— ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) Check all that apply): ❑ Sale of Commercially Pre- ❑ PHF Cooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held for Packaged Non-PHFs More Than a Single Meal Service. ❑ Sale of Commercially Pre- O Preparation Of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly Packaged PHFs Cold Holding For Single Meal Susceptible Population Facility Service. ❑ Delivery of Packaged PHFs ❑ Sale Of Raw Animal Foods Intended a Vacuum Packaging/Cook Chill to be Prepared by Consumer. ❑ Reheating of Commercially Q Customer Self -Service ❑ Use Of Process Requiring A Variance And/Or Processed Foods For Service HACCP Plan (including bare hand contact Within 4 Hours. alternative, time as a public health control ❑ Customer Self -Service Of Non- o Ice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Animal PHF and Non -Perishable Foods Retail Sale Origin. Only. ❑ Preparation Of Non-PHFs (3 Juice Manufactured and Packaged n Prepares Food/Single Meals for Catered for Retail Sale Events or Institutional Food Service ❑ Utters Kit rnr in r3uiK �tuannues Other (Describe): To be completed by the Board of Health t a , ca Retail Permit Fee: Retain Sale of Salvage, Out of Date or Payment is due with application Reconditioned Food 1, the undersigned, attest to the accuracy of th information provided in this application and I affirm that the food establishment operation will comply with 105 MR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 59 000 and the federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A,1 certiAvundor the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law, 25) Social Security Number or Federal ID:t ` U 26) Signature of Individual or Corporate Name: 1,v:f0r't _Ott f'-r l C TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. E G i Signature of Ind?vidual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "Social Security No. (Voluntanj) or Federal Identification Number 'This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. CAUsers\sleite\Desktop\Scott's ooeumentsWood Establishments- Temp\TAX CERTIFICATION FOKM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kip 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: i Vtt-<Tka l_ 5P(-lrl lr Address: City/State/Zip:� V CVX l 4 lPhone #: Are you an employer? Check the appropriate box: 1. 1 am a employer with _ } employees (full and/ or part-th-ne).* 1 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' camp. insurance required]" 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. ❑ Restaut'ant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.0 Health Care 12. [I Other iii (iJ 1.1 *Any applicant that checks box #1 must also rill out the section below showing their workers' compensation policy intonnation. ** if the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # 1. I am art emplover that is providing workers' contpettsation insrtrance for my employees. Below is the policv information. Insurance Company Name: i D '� it S ,� � &- n Insurer's Address: c,gc� Lt t � c City/State/Zip: Wig° t% Policy # or Self -ins. Lic. # 0 Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, lder the pains and penalties ofperjury that the Information provided above is true and correct. Date- 0, l 4 ti Phone #: Official use only. Do not write in this area, to be completed by clty or town offlcial. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: WWW,niass.gov/dia Phone #: 0912112016 13:22 5085433278 JED INSURANCE PAGE 01101 NATUR-3 OP ID: KDU '? CERTIFICATE OF LIABILITY INSURANCE DATCtM 0912111201612016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT$ UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT, If the certificate holder Is an ADDITIONAL INSURED, the pollcy(IeS) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and con(IM009 of the Polley, certain policies rosy require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement s). PRODUCER J.E.D. Insurance & Financial Service Agencyy, Inc. 30 Meohanlc S{rest Ste, 5 Foxboro MA 02039 John E. Bustin, CPCU, CLU NAMGACT .fahn Dustin, CPCU, CLU _ PHONE508-5543-1067 j'AIC Na)j 506'543532'78 , RIC, No, 6xt1' ..--- -MAIL _ ADORBss_..__,,.._ _. INSURER(S)AFFORDINO•gOVFAAaF NAICtF_ ___ INSURER A: Hartford Fire Insurance Co. _ 19682 _ INSURED Nature Springs Water Co., Inc. 55 Franklin Street Needham, MA 02494 INSURER a t ..._._ ___..........._.-..__ INSURER 0: _ INRUFtER 0! INSURER 61 EACH OCCURRENCE $ PREMISES fie oocurrence iNBURER r: CLAIMS -MAGE 1:1 OCCUR THIS I$ TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES OE8CRi8ED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INR LTR TYPE OV INSURANCE Mansfield, MA 02048 AUTHOR17POREPRESENTATIVE POLIOYNUmorn MMrd YY MMIDDNYYY LIMITS COMMERCIAL OENERA4 LIABILITY EACH OCCURRENCE $ PREMISES fie oocurrence CLAIMS -MAGE 1:1 OCCUR „5 MED BXP (Any one arson) $ r PERSONAL A ADV INJURY 3 JY G_E_N'L AGGREGATE LIMIT AFFLIES PER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ POLICY ❑ JEC ❑ Loc 8 OTHER; ed 08GtleDI31NGLE LIMIT $ AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ ANY AUTO BQDILY INJURY (Per scddenll S - IED AUTOS AUTEOULEO -' NON-0VtNOS ED PR r'FR'I'r upMn '$� HIRED AUTOS AUTOS (�e11A1 dont) — $ UMBRELLA LIABOCCUR EACH OCC"URRENOE $ AOQREGATE EXCESSLIAti HCLAIMS-MAOL RETENTIONS WORKERS COMPENSATION X STATUTE ERH _ A AND 6MPLOY6RS' ARTNEWIAVILITY ANY PROPRIETOR/PARTNERJEXECUTIVE YIN OBWECOK2751 09/1712016 0811712017,000 E.L.ElEACH ACCIDENT $ � 00 E.L. DISEASE -EA EMPLOYE $ 1,000,000 . �.. --r OFFICERIMEMBER EXCLUDED? u (Wndstary In NH) N 1 A If es rleasripa under D$RI ION F OPERATIONS Bala v E.L. DISEASE. POLICY LIMIT S 1,000,0D DESCRIPTION OF OPERATIONS/ LOCATIONS I vriMICLas (ACORD 101, Addlttonol Remarks Sahodulo, may be s taohod It mora epee IR raqulmd) RE: A Taste of Tri -Town Event Held On October d, 2016. MANSFIE SHOULD ANY OF THE ABOVE b@SevRIBE6 POLICIES BE CANCELLED BEFORE Mansfield Board Of Wealth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, 6 Park Row Mansfield, MA 02048 AUTHOR17POREPRESENTATIVE WJ 'rtlpty-1,174 Muvnu •avrcr vr�n IVIra nu „�nw ,nnn, rau. ACORD 25 (2014101) The ACORD name and logo are registered nnafks Of ACORD I told ' • •f _ Date � ` . i G% *Put the name of your restaurant on first line then sign the form. request a waiver of the Food Service Permit Fee for the following reason: Taste of Tri -Town Food Festival on 10/4/16 located at the Xfinity Center in Mansfield Thank you, 11 Z2:�- Signature 6 Title